This entire statute falls under the category “Network Adequacy.”  See the bold section below to see the text falling under “Continuity of Care Post-Contract.”

Section 6.6.8801. Definitions

The following definitions, in addition to those contained in 33-36-103 , MCA, apply to this chapter:

(1) “Access plan” means a document filed by a health carrier with the commissioner that complies with the standards set forth in ARM 6.6.8805 through 6.6.8807 and 33-36-201 , MCA.

(2) “Advanced practice registered nurse” means a nurse midwife, a nurse anesthetist, a nurse practitioner, or a clinical nurse specialist.

(3) “Geographic service area” means a geographic area of Montana in which a health carrier has a network that has been deemed adequate by the commissioner.

(4) “Mid-level provider” means a physician assistant-certified or an advanced practice registered nurse.

(5) “Non-urgent care with symptoms” means care required for an illness, injury, or condition with symptoms that do not require care within 24 hours to prevent a serious risk of harm but do require care that is neither routine nor preventive in nature.

(6) “Primary care provider (PCP)” means a physician, mid-level provider, federally qualified health center or rural health clinic as defined in ARM 37.86.4401, migrant health center, or other community-based provider that is designated by a health carrier to supervise, coordinate, or provide initial or continuing care to an enrollee, and if required by the health carrier, initiate a referral for specialty care services rendered to the enrollee.

(7) “Specialty provider” or “specialist” means a physician or other provider whose area of specialization is an area other than general medicine, family medicine, general internal medicine, or general pediatrics. A provider whose area of specialization is obstetrics and/or gynecology may be either a PCP or a specialist within the meaning of this rule.

(8) “Urgent care” means those health care services that are not emergency services but that are necessary to treat a condition or illness that could reasonably be expected to present a serious risk of harm if not treated within 24 hours.

Section 6.6.8805. Access Plan Filing and Review Guidelines

(1) When a health carrier submits a proposed access plan to the commissioner for review and approval, the commissioner will either approve, disapprove, or request additional information on the proposed plan within 60 calendar days. The commissioner has a total of 60 calendar days to review and issue a decision concerning any proposed access plan, not including any 30 calendar day response period that may be granted a health carrier proposing the plan. The commissioner may grant up to two 30 day response periods during the review of each access plan.

(2) During the commissioner’s review of its proposed access plan, a health carrier must respond to the commissioner’s request for information within 30 calendar days after the date of the request. If the response remains incomplete, the commissioner may grant the health carrier a second 30 calendar day period within which to submit a complete response. If, after two requests by the commissioner for information, the health carrier fails to provide information that the commissioner deems sufficient to satisfy its requests, the access plan will be disapproved and the health carrier will be required to submit a new proposed access plan prior to enrolling initial or additional enrollees.

(3) The total number of days allowed for the review of a given proposed access plan may not exceed 120 calendar days, including both time spent by the commissioner in review of the proposed plan and any time granted to a health carrier to respond to the commissioner’s requests for additional
information.

Section 6.6.8806. Access Plan Updates

(1) Health carriers shall be responsible for monitoring the status of their networks and must submit an updated access plan to the commissioner within 30 calendar days after a material change in the status of their network. For the purposes of this rule, a material change is a change in the composition of a health carrier’s provider network or a change in the size or demographic characteristics of the population enrolled with the health carrier that renders the health carrier’s network non-compliant with one or more of the network adequacy standards set forth in ARM 6.6.8815 , 6.6.8819 , and 6.6.8827 . If the revised access plan is not submitted within 30 calendar days after the material change in network status occurs, the health carrier must cease enrolling new recipients in the affected geographic service area until the revised access plan is approved by the commissioner. Review of the revised access plan is subject to the procedures and consequences outlined in ARM 6.6.8805 .

(2) In addition to the requirement in (1):

(a) the health carrier must submit an updated access plan to the commissioner pursuant to 33- 36-201(4), MCA; and

(b) health carriers must file an updated access plan with the commissioner if the number of providers in the overall provider network or in any specialty provider network decreases by more than 5% during the year in any single geographic service area or in the overall network. The carrier must file the plan within 30 days of the date the carrier learns of the decrease.

Section 6.6.8807. Access Plan Specifications.

(1) In addition to meeting the requirements of 33-36-201 (6) , MCA, an access plan for each health carrier offered in Montana must describe or contain the following:

(a) a list of participating providers which describes the type of provider, their specialty or credentials, and also their names, business addresses, zip codes, and phone numbers. The list must indicate which providers are accepting new patients;

(b) the health carrier’s policy for making referrals within and outside of the network including, at a minimum, the health carrier’s method for complying with each of the standards set forth in ARM 6.6.8828 , 6.6.8829 and 6.6.8835 ;

(c) the health carrier’s process for monitoring on a periodic basis the need for and satisfaction with health care services of the enrolled population and ensuring on an ongoing basis, the sufficiency of the network to meet those needs and, at a minimum, the health carrier’s methods for complying with each of the standards set forth in ARM 6.6.8840 ;

(d) the health carrier’s policy to address the needs of enrollees with limited English proficiency and/or illiteracy, those with diverse cultural and ethnic backgrounds, and those with physical and mental disabilities, in order to ensure that these characteristics do not pose barriers to gaining access to services. The policy shall, at a minimum, describe the health carrier’s methods for complying with each of the standards set forth in ARM 6.6.8836 ; and

(e) a copy of the health benefit plan’s booklet or policy or certificate of coverage, a summary of benefits for each policy (if available) , the list of network providers for each policy, and any other important information about the health carrier’s services and features which must be provided by the health carrier to either potential enrollees or covered enrollees. This information must be presented in language that is comprehensible to the average layperson. The information to be provided includes, but is not limited to:

(i) a listing of participating providers, as described in (1)(a);

(ii) a summary description of the health carrier’s standards for provider credentials and methodology for reviewing provider credentials on an ongoing basis required by ARM 6.6.8816 ;

(iii) the procedures in place for selecting and changing providers;

(iv) the health carrier’s policy regarding enrollee responsibility for co-insurance, copayments, and deductibles;

(v) a detailed description of the health carrier’s procedures along with authorization for specialty care that comply with ARM 6.6.8828 , a schedule of the fees, including coinsurance, copayments, and deductibles, for which an enrollee will be responsible;

(vi) policies pertaining to approval of and access to emergency services that meet the requirements of ARM 6.6.8814 ;

(vii) telephone numbers and procedures for contacting an authorized representative of the health carrier who can facilitate review of post-evaluation or post-stabilization services required immediately after receipt of emergency services;

(viii) a description of the health carrier’s grievance procedures, including specific instructions and guidelines for filing and appealing grievances;

(ix) a policy regarding use of and payment for in-network services; and

(x) a policy regarding use of and payment for out-of-network services;

(f) the health carrier’s method of providing and paying for emergency screening and services 24 hours a day, 7 days a week, in accordance with ARM 6.6.8814 ;

(g) a process for enabling enrollees to change primary care professionals that meets the standards of ARM 6.6.8835 ;

(h) a process for transfer of enrollees to other providers must include a provision for transitional care as described in ARM 6.6.8829 ;

(i) the process used to address and correct instances where a health carrier has an insufficient number or type of participating providers accessible to enrollees to provide a covered benefit. This process must comply with the requirements of ARM 6.6.8819 and 6.6.8820; and

(j) the health carrier’s procedures for complying with geographic accessibility requirements as outlined in ARM 6.6.8819 and 6.6.8820 .

Section 6.6.8808. Access Criteria

(1) The commissioner will utilize the criteria set forth in this chapter and Title 33, chapter 36, MCA, to determine whether the network maintained by a health carrier offering a managed care plan in Montana is sufficient in numbers and type of providers.

Section 6.6.8814. Mandatory Coverage

(1) The following must be reimbursed without regard to either prior authorization or the contractual relationship between the health carrier and the provider:

(a) emergency services as defined in 33-36-103 , MCA;

(b) covered services that do not meet the criteria for emergency services, but which were medically necessary and immediately required because an unforeseen illness, injury or condition occurred when the enrollee was outside the health carrier’s geographic service area and could not reasonably access services through the health carrier’s network of providers; and

(c) renal dialysis, if covered, that is provided while the enrollee is outside the health carrier’s service area for no more than 30 calendar days per year.

Section 6.6.8815. Provider-Enrollee Ratio Requirements

(1) In order to be deemed adequate, a health carrier’s network must include one mid-level PCP per 1,500 projected enrollees or one physician PCP per 2,500 projected enrollees.

Section 6.6.8816. Verification of Provider Credentials

(1) Each health carrier shall establish and describe in its access plan the criteria utilized to review the credentials of the providers in its network. A health carrier must require a provider’s credentials to be reviewed prior to the health carrier employing or entering into contractual relationship with a provider and a provider’s credentials are to be reverified at least every 3 years thereafter.

Section 6.6.8819. Geographic Access Criteria

(1) In order to be deemed adequate, a provider network must fulfill all access criteria of the rules in this chapter within the following geographic restrictions:

(a) to the extent that services are covered by the health carrier, the health carrier must have an adequate network of primary care providers; a hospital, critical access hospital, or medical assistance facility; and a pharmacy that is located within a 30 mile radius of each enrollee’s residence or place of work, unless:

(i) the usual and customary travel pattern of the general population within the service area to reach health care providers is further, and if the fact that the usual and customary travel pattern exists is documented by the health carrier; or

(ii) the provider is available but does not meet the health carrier’s reasonable credentialing requirements; and

(b) if no qualified provider for a service covered by the plan exists within a 30 mile radius of an enrollee’s residence or place of work, the health carrier must document how covered services will be provided at no additional charge to enrollees through referrals to qualified providers outside the 30 mile radius.

(2) Enrollees may, at their discretion, select participating primary care providers located farther than 30 miles from their homes and/or places of business.

(3) When an eligible employee in a group health plan neither resides nor works within a 30 mile radius of the network established pursuant to (1) , the network may be deemed adequate subject to the following conditions:

(a) Insured employees living and working outside the 30 mile radius of the primary place of work of their employer, as well as their dependents, may not be penalized either in benefits or by being required to travel outside the 30 mile radius from their own place of work to receive routine treatment typically provided by a primary care provider.

(b) The health carrier may require employees to utilize a network primary care provider for referrals, including for referrals for routine treatment provided by a primary care provider. If such a requirement is imposed, access to the network primary care provider must be available to the insured by phone at no cost to the insured. A toll free number to the health carrier would satisfy this requirement.

(c) At the time of initial selection or the renewal of a managed care plan, the maximum number of eligible employees residing and working outside the 30 mile radius of the primary place of work may not exceed the following:

(i) for groups with two to five employees, one;

(ii) for groups with six to 15 employees, two;

(iii) for groups with 16 to 30 employees, three, and

(iv) for groups with 30 or more employees, 10% of the employees.

Section 6.6.8820. Exceptions to Geographic Access Criteria

(1) The commissioner may grant exceptions to the geographic accessibility standard in ARM 6.6.8819 if good cause to do so exists.

(2) Good cause includes but is not limited to the circumstance where the health carrier has documented a good faith effort to negotiate a contract with local providers but has failed to reach an agreement within 60 days after the offer of a written contract from the health carrier. A good faith effort means an honest effort with the intent to deal fairly with providers and includes offering terms and conditions at least as favorable as those offered to other entities providing the same or similar services.

Section 6.6.8821, Service Areas.

(1) A network’s service area may encompass more than one geographic service area provided the network in all such areas meets the network adequacy criteria.

Section 6.6.8827.  Maximum Wait Times for Appointments

(1) An adequate network must meet the following criteria for all enrollees:

(a) emergency services must be available and accessible at all times;

(b) urgent care appointments must be available within 24 hours;

(c) appointments for non-urgent care with symptoms must be available within 10 calendar days;

(d) appointments for immunizations must be available within 21 calendar days; and

(e) appointments for routine or preventive care must be available within 45 calendar days.

Section 6.6.8828. Referral and Specialty Care Requirements

(1) Procedures for referrals must be clearly outlined in the access plan, in literature provided to all enrollees, and in literature or contracts provided to all participating providers.

(2) Women and adolescent females who do not designate a gynecological health care provider as their PCP must be allowed direct access (without prior authorization or referral from a PCP) to a participating provider whose area of specialization is gynecology for routine gynecological care no less frequently than one time per year.

(3) Pregnant females must be allowed direct access, without prior authorization or referral from a PCP, to a participating provider whose area of specialization is obstetrics.

(4) An enrollee must be allowed to designate a participating pediatrician, family practice physician, or, if the health carrier allows a mid-level provider to be a PCP, a mid-level provider specializing in primary care of children as the PCP for the enrollee’s children and/or adolescents who are covered by the health carrier.

(5) The access plan must include a process to address and correct instances where a health carrier has an insufficient number or type of participating providers accessible to enrollees to provide a covered benefit. In these instances, the health carrier must ensure that covered services are provided at no greater cost to the enrollee than if the services were obtained from a participating provider.

(6) The access plan must include policies and procedures by which an enrollee with a condition that requires ongoing care from a specialist may obtain a standing referral to a participating specialty provider. For purposes of this rule, standing referral means a referral for ongoing care to be provided by a participating specialty care provider that authorizes a series of visits with the specialist for either a specific time period or a limited number of visits, and which is provided according to a treatment plan approved by the carrier and developed by the enrollee’s PCP, the specialty provider, and the enrollee.

Continuity of Care Post-Contract

Section 6.6.8829. Continuity of Care and Transitional Care

(1) A health carrier must allow the following new enrollees to continue to receive services from their previous providers for the time periods noted below, so long as those providers agree to abide by the payment rates, credentialing, referral process, quality-of-care standards and protocols, and reporting standards that apply to comparable participating providers:

(a) a new enrollee with a life-threatening, disabling or degenerative condition may obtain care from their previous provider for a period of 60 days, beginning the date of the enrollee’s enrollment with the health carrier;

(b) a new enrollee who has received a diagnosis of terminal illness with life expectancy of less than 6 months, may continue to obtain care from their previous provider until death if it occurs prior to the end of the 6 month period, or, if it does not, for a period of 6 months from the date of the enrollee’s enrollment with the health carrier, unless the period is extended after the enrollee’s medical needs and the appropriateness of requiring a transition to a participating provider are reassessed. Such a reassessment must be conducted at or before the end of the 6 month period by the health carrier for such a terminally ill enrollee; and

(c) a new enrollee in the second or third trimester of pregnancy may obtain care from their previous provider through the completion of postpartum care.

(2) A health carrier must allow enrollees with the medical conditions described in (1) (a) through (1)

(c) above to continue to receive services from their existing providers when their provider’s contract is terminated by the carrier without cause or when the provider voluntarily terminates their contract with the carrier, so long as those providers agree to abide by the payment rates, credentialing, referral process, quality-of-care standards and protocols, and reporting standards which apply to comparable participating providers. The time periods during which such continued services are allowed are the same as those specified in (1) (a) through (1) (c) above, with the exception that, for the conditions described in (1) (a) and (1) (b) , the time period begins on the date the provider’s contract is terminated, rather than the date of the enrollee’s enrollment with the health carrier.

(3) A health carrier may not hold an enrollee covered by this rule responsible for any additional payments, copayments, co-insurance or deductibles beyond what would be required if the services were provided by a participating provider.

Section 6.6.8835. Selecting and Changing Providers

(1) Enrollees must be allowed to change primary care providers at least once per benefit year.

(2) The health carrier will monitor the frequency of enrollees’ requests to change primary care providers and shall have in place a policy to address situations in which a provider has patient turnover rates that are significantly higher than the average rate within the health carrier’s network.

Section 6.6.8836. Removal of Barriers to Access

(1) The health carrier must have a policy in place to address the needs of enrollees with limited English proficiency and/or illiteracy, those with diverse cultural and ethnic backgrounds, and those with physical and mental disabilities, in order to insure that these characteristics do not pose barriers to gaining access to services. This policy shall, at a minimum, describe the health carrier’s methods for providing the following:

(a) interpreter services to allow effective communication regarding treatment, medical history and health education;

(b) appropriate and sufficient personnel, physical resources and equipment to meet the basic health care needs of these enrollees; and

(c) education to providers and other employees about the needs of these covered persons.

Section 6.6.8840. Monitoring the Network

(1) The health carrier must establish methods for periodically assessing the sufficiency of the network to meet the health care needs of covered persons as well as assessing their satisfaction with services. The following must be included in this assessment:

(a) changes in volume of specialty services needed;

(b) changes in number of primary care providers needed;

(c) other changes in health care utilization that might indicate changes in the health status of covered persons;

(d) enrollee satisfaction with billing and record keeping;

(e) provider satisfaction with billing and record keeping;

(f) enrollee satisfaction with educational materials available to them;

(g) enrollee satisfaction with 24-hour access to medical advice and services;

(h) enrollee satisfaction with the referral process; and

(i) provider satisfaction with the referral process.

Section 6.6.8841. Letters of Intent

(1) In order to demonstrate that its network is adequate, a health carrier may utilize letters of intent from individual providers with whom it does not yet have a contract, so long as the providers do not constitute more than 15% of the total network. If letters of intent from providers are utilized, within 6 months after the access plan is submitted to the commissioner the health carrier must submit to the commissioner verification that it has an adequate network.

Section 6.6.8842. Responsibility of Contracted Services

(1) A health carrier offering a managed care plan that uses a contractual arrangement to provide services to covered persons remains responsible for meeting the requirements of this chapter, including documentation requirements.

https://rules.mt.gov/browse/collections/aec52c46-128e-4279-9068-8af5d5432d74/sections/5961a49c-5a67-4e36-96f2-489269a4b169